Covered Entity Details

RRC100105-26 INDIAN RIVER MEMORIAL HOSPITA.L (Terminated) - information as of 4/29/2025 11:52:29 PM

Main Details

Name

INDIAN RIVER MEMORIAL HOSPITA.L

Subdivision Name

Vero Beach Pointe West - URGENT CARE CLINIC - Pointe West Urgent Care

Type

Rural Referral Center

Rural

340B ID

RRC100105-26

Medicare Provider Number

100105

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

1/4/2022

Participating Start Date

4/1/2022

Participating Approval Date

2/4/2022

Last Recertification Date

8/22/2023

Termination Date
Termination Reason

7/1/2024
DSH percentage below statutory minimum

Contacts

Authorizing Official

Indian River Memorial Hospital
Charmaine Rochester, Chief Financial Officer
(786) 848-2854

Primary Contact

Cleveland Clinic
Jonathan Williams, Senior Director of Pharmacy - 340B
(216) 444-8884

Addresses

Street Address

1960 POINTE WEST DR
102
VERO BEACH, FL 32966

Billing Address

Indian River Memorial Hosp
1000 36th Street
VERO BEACH, FL 32960

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
No records to display.

Medicaid Billing

At this site, will the covered entity bill Medicaid fee-for-service for drugs purchased at 340B prices?
Yes

State	Medicaid Number	NPI Number
FL	010104400	1376512988

Shipping Addresses

Same as Street Address

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Carve-In Effective Date	Termination Date	Last Updated On
No records to display.

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
RRC100105-01	Child	RRC	INDIAN RIVER MEMORIAL HOSPITA.L	Sebastian Medical Suites - WALK-IN CARE - Sebastian Urgent Care	801 WELLNESS WAY	SEBASTIAN	FL	Terminated
RRC100105-02	Child	RRC	INDIAN RIVER MEMORIAL HOSPITA.L	Sebastian Medical Suites - ORTHOPAEDIC SURGERY - Orthopedic Practice	801 WELLNESS WAY	SEBASTIAN	FL	Terminated
RRC100105-03	Child	RRC	INDIAN RIVER MEMORIAL HOSPITA.L	Sebastian Medical Suites - FAMILY MEDICINE - FAMILY PRACTICE NORTH	801 WELLNESS WAY	SEBASTIAN	FL	Terminated
RRC100105-04	Child	RRC	INDIAN RIVER MEMORIAL HOSPITA.L	Sebastian Medical Suites - ANTICOAGULATION - MEDICATION MANAGEMENT	801 WELLNESS WAY	SEBASTIAN	FL	Terminated
RRC100105-05	Child	RRC	INDIAN RIVER MEMORIAL HOSPITA.L	Sebastian Medical Suites - CARDIOVASCULAR MEDICINE - CARDIOLOGY PRACTICE	801 WELLNESS WAY	SEBASTIAN	FL	Terminated
RRC100105-06	Child	RRC	INDIAN RIVER MEMORIAL HOSPITA.L	Vero Beach 9th St SW - FAMILY MEDICINE/INTERNAL MEDICINE - Primary Care South	4165 9TH ST SW	VERO BEACH	FL	Terminated
RRC100105-07	Child	RRC	INDIAN RIVER MEMORIAL HOSPITA.L	Vero Beach Chronic Care - WOUND - Wound Care	3650 10TH CT	VERO BEACH	FL	Terminated
RRC100105-08	Child	RRC	INDIAN RIVER MEMORIAL HOSPITA.L	Vero Beach Health and Wellness Center - INFECTIOUS DISEASES - INFECTIOUS DISEASE PRACTICE	3450 11TH CT	VERO BEACH	FL	Terminated
RRC100105-09	Child	RRC	INDIAN RIVER MEMORIAL HOSPITA.L	Scully Welsh Cancer Center - HEMATOLOGY/ONCOLOGY/BREAST - Medical Oncology Practice	3555 10TH CT	VERO BEACH	FL	Terminated
RRC100105-10	Child	RRC	INDIAN RIVER MEMORIAL HOSPITA.L	Vero Beach Health and Wellness Center - ELECTROPHYSIOLOGY - Electrophysiology	3450 11TH CT	VERO BEACH	FL	Terminated
RRC100105-11	Child	RRC	INDIAN RIVER MEMORIAL HOSPITA.L	Vero Beach Health and Wellness Center - ORTHOPAEDIC SURGERY - Orthopedic Practice	3450 11TH CT	VERO BEACH	FL	Terminated
RRC100105-12	Child	RRC	INDIAN RIVER MEMORIAL HOSPITA.L	Vero Beach Health and Wellness Center - CARDIAC SURGERY - STOWE PRACTICE	3450 11TH CT	VERO BEACH	FL	Terminated
RRC100105-13	Child	RRC	INDIAN RIVER MEMORIAL HOSPITA.L	Vero Beach Partners in Women's Health - OB/GYN - PARTNERS IN W.H.	1050 37TH PL	VERO BEACH	FL	Terminated
RRC100105-14	Child	RRC	INDIAN RIVER MEMORIAL HOSPITA.L	Vero Beach Health and Wellness Center - NEUROSURGERY - Neurosurgery Practice	3450 11TH CT	VERO BEACH	FL	Terminated
RRC100105-15	Child	RRC	INDIAN RIVER MEMORIAL HOSPITA.L	Scully Welsh Cancer Center - HOP - AMBULATORY INFUSION	3555 10TH CT	VERO BEACH	FL	Terminated
RRC100105-16	Child	RRC	INDIAN RIVER MEMORIAL HOSPITA.L	Scully Welsh Cancer Center - ONCOLOGY - ONCOLOGY INFUSION	3555 10TH CT	VERO BEACH	FL	Terminated
RRC100105-17	Child	RRC	INDIAN RIVER MEMORIAL HOSPITA.L	Vero Beach Chronic Care - INTERNAL MEDICINE - MEDICATION MANAGEMENT	3650 10TH CT	VERO BEACH	FL	Terminated
RRC100105-18	Child	RRC	INDIAN RIVER MEMORIAL HOSPITA.L	Vero Beach Health and Wellness Center - FAMILY MEDICINE/INTERNAL MEDICINE - VERO PRACTICE	3450 11TH CT	VERO BEACH	FL	Terminated
RRC100105-19	Child	RRC	INDIAN RIVER MEMORIAL HOSPITA.L	Vero Beach Health and Wellness Center - UROLOGY - UROLOGY PRACTICE	3450 11TH CT	VERO BEACH	FL	Terminated
RRC100105-20	Child	RRC	INDIAN RIVER MEMORIAL HOSPITA.L	Vero Beach Health and Wellness Center - CARDIOVASCULAR MEDICINE - CARDIOLOGY PRACTICE	3450 11TH CT	VERO BEACH	FL	Terminated
RRC100105-21	Child	RRC	INDIAN RIVER MEMORIAL HOSPITA.L	Vero Beach Health and Wellness Center - INTERVENTIONAL CARDIOLOGY - INTERVENTIONAL PRACTICE	3450 11TH CT	VERO BEACH	FL	Terminated
RRC100105-22	Child	RRC	INDIAN RIVER MEMORIAL HOSPITA.L	Vero Beach Health and Wellness Center - RHEUMATOLOGY - RHEUMATOLOGY PRACTICE	3450 11TH CT	VERO BEACH	FL	Terminated
RRC100105-23	Child	RRC	INDIAN RIVER MEMORIAL HOSPITA.L	Vero Beach Health and Wellness Center - NEUROLOGY - NEUROLOGY PRACTICE	3450 11TH CT	VERO BEACH	FL	Terminated
RRC100105-24	Child	RRC	INDIAN RIVER MEMORIAL HOSPITA.L	Vero Beach 35th Ln - DERMATOLOGY - DERMATOLOGY PRACTICE	1155 35TH LN	VERO BEACH	FL	Terminated
RRC100105-25	Child	RRC	INDIAN RIVER MEMORIAL HOSPITA.L	Vero Beach Pointe West - FAMILY MEDICINE - FAMILY PRACTICE POINTE WEST	1960 POINTE WEST DR	VERO BEACH	FL	Terminated
RRC100105-26	Child	RRC	INDIAN RIVER MEMORIAL HOSPITA.L	Vero Beach Pointe West - URGENT CARE CLINIC - Pointe West Urgent Care	1960 POINTE WEST DR	VERO BEACH	FL	Terminated
RRC100105-27	Child	RRC	INDIAN RIVER MEMORIAL HOSPITA.L	Vero Beach Health and Wellness Center - GENERAL SURGERY - General Surgery Practice	3450 11TH CT	VERO BEACH	FL	Terminated
RRC100105-28	Child	RRC	INDIAN RIVER MEMORIAL HOSPITA.L	Vero Beach Chronic Care - REHAB THERAPY - Indian River Therapy	3650 10TH CT	VERO BEACH	FL	Terminated
RRC100105-29	Child	RRC	INDIAN RIVER MEMORIAL HOSPITA.L	Vero Beach Pointe West - ANTICOAGULATION - MEDICATION MANAGEMENT	1960 POINTE WEST DR	VERO BEACH	FL	Terminated
RRC100105-30	Child	RRC	INDIAN RIVER MEMORIAL HOSPITA.L	Vero Beach Health and Wellness Center - INTERVENTIONAL NEUROLOGY - INTERVENTIONAL NEUROLOGY	3450 11TH CT	VERO BEACH	FL	Terminated
RRC100105-31	Child	RRC	INDIAN RIVER MEMORIAL HOSPITA.L	Vero Beach Health and Wellness Center - GASTROENTEROLOGY - GASTROENTEROLOGY PRACTICE	3450 11TH CT	VERO BEACH	FL	Terminated
RRC100105-32	Child	RRC	INDIAN RIVER MEMORIAL HOSPITA.L	VERO BEACH PRIMARY CARE - Family Medicine - PRIMARY CARE VERO INTERNAL MEDICINE	1265 36TH ST	VERO BEACH	FL	Terminated
RRC100105-33	Child	RRC	INDIAN RIVER MEMORIAL HOSPITA.L	Vero Beach Health and Wellness Center - PULMONARY MEDICINE - HEALTH & WELLNESS PULMONOLOGY	3450 11TH CT	VERO BEACH	FL	Terminated
RRC100105-34	Child	RRC	INDIAN RIVER MEMORIAL HOSPITA.L	VERO BEACH 35th LN - Rheumatology - HEALTH & WELLNESS RHEUMATOLOGY	1155 35TH LN	VERO BEACH	FL	Terminated
RRC100105-35	Child	RRC	INDIAN RIVER MEMORIAL HOSPITA.L	VERO BEACH 35th LN - DERMATOLOGY - CANCER CENTER DERMATOLOGY	1155 35TH LN	VERO BEACH	FL	Terminated
RRC100105-36	Child	RRC	INDIAN RIVER MEMORIAL HOSPITA.L	Vero Beach Health and Wellness Center - ENDOCRINOLOGY - HOSPITAL ENDOCRINE MEDICINE	3450 11TH CT	VERO BEACH	FL	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	7/1/2024 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		5/30/2024 12:00:00 AM	6/5/2024 7:31 AM
Details	State	Update	Termination Request	Active	To Be Terminated	6/5/2024 7:31 AM
Terminations	Termination Date	Update	Termination Request		7/1/2024 12:00:00 AM	6/5/2024 7:31 AM
Terminations	Termination Effective Date	Update	Termination Request		5/31/2024 12:00:00 AM	6/5/2024 7:31 AM
Terminations	Termination Reason	Update	Termination Request		DSH percentage below statutory minimum	6/5/2024 7:31 AM
Contacts	Authorizing Official	Update	Change Request	Fuller, Warren SENIOR VP CHIEF FINANCIAL OFFICER Cleveland Clinic Indian River Hospital 7725674311-1321	Rochester, Charmaine Chief Financial Officer Indian River Memorial Hospital 7868482854	5/30/2024 12:07 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	1376512988 (NC)		11/8/2023 5:46 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	003101612A (GA)		11/8/2023 5:46 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1376512988 (NC)		11/8/2023 5:46 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1376512988 (GA)		11/8/2023 5:46 PM
Contacts	Primary Contact	Update	Profile Change Request	Williams, Jonathan Director of Pharmacy - 340B Cleveland Clinic 2164448884	Williams, Jonathan Senior Director of Pharmacy - 340B Cleveland Clinic 2164448884	8/27/2023 3:57 PM
Details	Last Recertification Date	Update	Recertification	9/13/2022 7:13:03 AM	8/22/2023 7:05:17 AM	8/22/2023 7:05 AM
Details	Last Recertification Date	Update	Recertification		9/13/2022 7:13:03 AM	9/13/2022 7:13 AM
Contacts	Authorizing Official	Update	Change Request	Vanlith, Richard Vice President Cleveland Clinic Indian River 7725674311-1046	Fuller, Warren SENIOR VP CHIEF FINANCIAL OFFICER Cleveland Clinic Indian River Hospital 7725674311-1321	8/29/2022 9:21 AM
Contacts	Authorizing Official	Update	Change Request	Turner, Ralph Chief Operating Officer Cleveland Clinic Indian River Hospital 7725674311-1062	Vanlith, Richard Vice President Cleveland Clinic Indian River 7725674311-1046	5/16/2022 12:30 PM
Details	State	Update		Approved	Active	4/1/2022 12:01 AM
Contacts	Signed By	Insert	New Registration		Turner, Ralph Chief Operating Officer Cleveland Clinic Indian River Hospital 7725674311-1062	2/4/2022 9:10 AM
Details	340B ID	Update	New Registration		RRC100105-26	2/4/2022 9:10 AM
Details	Entity Subname	Update	New Registration	Vero Beach Pointe West - URGENT CARE CLINIC	Vero Beach Pointe West - URGENT CARE CLINIC - Pointe West Urgent Care	2/4/2022 9:10 AM
Dates	Participating Approval Date	Update	New Registration		2/4/2022 9:10:12 AM	2/4/2022 9:10 AM
Details	State	Update	New Registration	Pending	Approved	2/4/2022 9:10 AM
Dates	Signed By Date	Update	New Registration		1/6/2022 3:18:54 PM	2/4/2022 9:10 AM
Dates	Start Date	Update	New Registration		4/1/2022 12:00:00 AM	2/4/2022 9:10 AM
Addresses	Main Address	Insert	New Registration		1960 POINTE WEST DR 102 VERO BEACH, FL 32966	1/4/2022 3:33 PM
Addresses	Billing Address	Insert	New Registration		Indian River Memorial Hosp 1000 36th Street VERO BEACH, FL 32960	1/4/2022 3:33 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/4/2022 3:33 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1376512988	1/4/2022 3:33 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NC	1/4/2022 3:33 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/4/2022 3:33 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		003101612A	1/4/2022 3:33 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		GA	1/4/2022 3:33 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/4/2022 3:33 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		010104400	1/4/2022 3:33 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		FL	1/4/2022 3:33 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1376512988	1/4/2022 3:33 PM
Medicaid Billing	NPI: State	Insert	New Registration		NC	1/4/2022 3:33 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1376512988	1/4/2022 3:33 PM
Medicaid Billing	NPI: State	Insert	New Registration		FL	1/4/2022 3:33 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1376512988	1/4/2022 3:33 PM
Medicaid Billing	NPI: State	Insert	New Registration		GA	1/4/2022 3:33 PM
Contacts	Primary Contact	Insert	New Registration		Williams, Jonathan Director of Pharmacy - 340B Cleveland Clinic 2164448884	1/4/2022 3:33 PM
Contacts	Authorizing Official	Insert	New Registration		Turner, Ralph Chief Operating Officer Cleveland Clinic Indian River Hospital 7725674311-1062	1/4/2022 3:33 PM
Details	Assistance Received From Date	Insert	New Registration			1/4/2022 3:33 PM
Details	Assistance Received To Date	Insert	New Registration			1/4/2022 3:33 PM
Details	Last Recertification Date	Insert	New Registration			1/4/2022 3:33 PM
Details	Grant Number	Insert	New Registration			1/4/2022 3:33 PM
Details	340B ID	Insert	New Registration			1/4/2022 3:33 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			1/4/2022 3:33 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			1/4/2022 3:33 PM
Details	Medicare Provider Number	Insert	New Registration		100105	1/4/2022 3:33 PM
Details	Entity Name	Insert	New Registration		INDIAN RIVER MEMORIAL HOSPITA.L	1/4/2022 3:33 PM
Details	NOFO Number	Insert	New Registration			1/4/2022 3:33 PM
Details	Program Code	Insert	New Registration		RRC	1/4/2022 3:33 PM
Details	Entity Subname	Insert	New Registration		Vero Beach Pointe West - URGENT CARE CLINIC	1/4/2022 3:33 PM
Dates	Participating Approval Date	Insert	New Registration			1/4/2022 3:33 PM
Details	State	Insert	New Registration		Pending	1/4/2022 3:33 PM
Dates	Registration Date	Insert	New Registration		1/4/2022 3:33:14 PM	1/4/2022 3:33 PM
Dates	Signed By Date	Insert	New Registration			1/4/2022 3:33 PM
Dates	Start Date	Insert	New Registration			1/4/2022 3:33 PM
Terminations	Termination Comments	Insert	New Registration			1/4/2022 3:33 PM
Terminations	Termination Date	Insert	New Registration			1/4/2022 3:33 PM
Terminations	Termination Effective Date	Insert	New Registration			1/4/2022 3:33 PM
Terminations	Termination Reason	Insert	New Registration			1/4/2022 3:33 PM